Provider Demographics
NPI:1992987713
Name:JACKS, ALAN FOWLER (M D)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:FOWLER
Last Name:JACKS
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 MALCOLM BLVD.
Mailing Address - Street 2:
Mailing Address - City:CONNELLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28612
Mailing Address - Country:US
Mailing Address - Phone:828-580-3555
Mailing Address - Fax:828-874-2111
Practice Address - Street 1:845 MALCOLM BLVD.
Practice Address - Street 2:
Practice Address - City:CONNELLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28612
Practice Address - Country:US
Practice Address - Phone:828-580-3555
Practice Address - Fax:828-874-2111
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601640208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1992987713Medicaid
NC891013EMedicaid
NC1013EOtherBCBS NC
NC1013EOtherBCBS NC
NC2233376AMedicare PIN